Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Villages of Lake Highlands
Dallas, TX · 126 certified beds · Last Life Safety survey May 16, 2025
CMS Certification Number 676268 · first certified November 2010
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Villages of Lake Highlands Assisted Living (8615 Lullwater Dr). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
7 citations — more than 44% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to July 2026), and past the point by which nine in ten TX facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 9, 2023 | 3 |
| April 18, 2024 | 1 |
| May 16, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-04-18 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-02-09 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-05-16 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-02-09 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 1 | 2023-02-09 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2025-05-16 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-05-16 |
What the citations cover
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 16, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 16, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 4, 2025) |
April 18, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 23, 2024) |
February 9, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (March 1, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 1, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 1, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.